RHIT Revenue Cycle Management 3 — Questions and Answers
Question 1: Which document sent by the payer details what was paid, denied, or adjusted on a claim?
- Explanation of Benefits (EOB) / Remittance Advice (RA) (Correct answer)
- Advance Beneficiary Notice (ABN)
- Notice of Claim Adjudication (NCA)
- Medicare Summary Notice (MSN)
Correct answer: Explanation of Benefits (EOB) / Remittance Advice (RA)
The EOB/RA is the document payers send to providers detailing payment decisions, adjustments, and denial reasons for submitted claims.
Question 2: A patient is covered by both a spouse's employer plan and their own employer plan. The process of determining which payer pays first is called:
- Subrogation
- Coordination of benefits (COB) (Correct answer)
- Dual eligibility determination
- Secondary claim processing
Correct answer: Coordination of benefits (COB)
Coordination of benefits establishes payment order when a patient has multiple insurance coverages to prevent overpayment.
Question 3: Under the MS-DRG system, what is the primary factor that determines a patient's DRG assignment?
- Length of stay
- Number of procedures performed
- Principal diagnosis with complications/comorbidities (CCs/MCCs) (Correct answer)
- Attending physician specialty
Correct answer: Principal diagnosis with complications/comorbidities (CCs/MCCs)
MS-DRG assignment is driven primarily by the principal diagnosis and the presence of complications or comorbidities (CC/MCC) that affect resource use.
Question 4: Which type of audit is conducted by Recovery Audit Contractors (RACs) to identify Medicare improper payments?
- Prospective audit
- Concurrent audit
- Retrospective (post-payment) audit (Correct answer)
- Internal compliance audit
Correct answer: Retrospective (post-payment) audit
RAC audits are retrospective, reviewing claims already paid by Medicare to identify overpayments or underpayments.
Question 5: A claim submitted without errors that meets all payer requirements on its first submission is called a:
- Clean claim (Correct answer)
- Accepted claim
- Certified claim
- Pre-adjudicated claim
Correct answer: Clean claim
A clean claim contains all required data elements, no errors, and is accepted for adjudication without additional information requests.
Question 6: Which coding guideline states that when a patient is admitted for a complication of surgery or other medical care, the complication code should be sequenced as the principal diagnosis?
- UHDDS guidelines
- OGCR Section II guideline (Correct answer)
- POA indicator rule
- Discharge disposition rule
Correct answer: OGCR Section II guideline
UHDDS/OGCR guidelines for principal diagnosis selection require sequencing the complication as the principal diagnosis when it is the reason for admission.
Question 7: Which of the following is an example of a front-end revenue cycle function?
- Claim submission
- Denial management
- Patient registration and insurance verification (Correct answer)
- Payment posting
Correct answer: Patient registration and insurance verification
Front-end revenue cycle functions occur before or at the time of service and include scheduling, registration, eligibility verification, and pre-authorization.
RHIT Revenue Cycle Management 3
Which document sent by the payer details what was paid, denied, or adjusted on a claim?